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Virtual house calls bring care to marginalized patients in Hamilton

By Dr. Dennis DiValentino

April 29, 2019

HAMILTON, ONT. – The Virtual House Call Project was started in 2017 to address a significant gap in access to care for patients who are considered marginalized. For clarity, a marginalized patient is one who cannot receive primary healthcare in a manner that is appropriate for their disease burden or needs in general, and consequently accesses ER and hospital services in lieu of primary care access.

This is a costly problem for the healthcare system and one that produces unnecessary suffering for patients and their families.

Usually, serious illness can be prevented with timely access to basic primary care services. These services are simply not accessible for marginalized patients who experience, in some cases, insurmountable barriers to healthcare access.

Limited mobility and serious mental health disorders are examples of common barriers to healthcare access. These barriers are usually compounded by poverty. The consequences range from the delivery of care that is unnecessarily excessive in terms of cost, to significant patient and family suffering, to premature and unnecessary death.

Our solution: The solution to this concern, like many current health concerns, lies in the application of technology. To reach the group of patients described as marginalized, my colleague, Dr. Richard Tytus and I developed a new tool called Virtual House Calls.

We were assisted by a $25,000 innovation grant from Joule, part of the Canadian Medical Association; the funding was used to acquire equipment. We’ve shouldered the additional costs of staff time and training, and the cost of delivering the service, as Ontario does not yet compensate physicians for ambulatory telemedical services. However, we believe it is the compassionate thing to do; and as telemedicine proves its worth, we hope the funding situation will change.

The Virtual House Call solution uses videoconferencing and also employs new peripheral devices that allow providers to conduct more high-level patient encounters, in a virtual fashion, than we ever could before. The provider remains in the office and is available to provide care to other patients. The patient remains in his or her home.

The technology: The goal of a virtual encounter is to best approximate the quality of an in-person encounter, primarily with respect to the collection of objective information.

Collecting subjective information remotely can be done in many ways, including by telephone. The first version of our platform included a Microsoft Surface Pro tablet, a USB enabled stethoscope and a USB enabled otoscope/dermoscope.

Several peripheral devices were tried, in order to determine the best possible devices for quality, reliability and interoperability.

The limitations of the devices trialled are discussed below. The platform is powered by a mobile Wi-Fi stick, such that there are no technical requirements on the patient end.

In terms of software, several software platforms were tested. The platform that we ended up using is called REACTS, a Canadian platform developed by a Montreal-based physician named Yanick Beaulieu. The REACTS platform is ideal for this type of service due to its ease-of-use for both providers, and nurses or aides operating on the patient interface.

It has a high level of interoperability, making it peripheral device agnostic, thus allowing greater flexibility with respect to upgrading peripheral devices and improving the quality of objective information attained.

All of the hardware is stored in a messenger bag to create the “Virtual House Call Bag”. This bag is completely mobile and can deliver care to essentially anywhere.

The service: We first delivered this service to patients who were identified by case managers at our local home care organization as being marginalized, and thus not receiving any type of primary care services.

We wanted to target patients who were known to be using hospitals for primary care services. We cared for 20 patients in the initial pilot.

The “Virtual Bag” was brought to the patient home by a nurse or healthcare aide at the request of the patient or another healthcare provider or service.

The first pilot conducted was a proof-of-concept and technology. We wanted to demonstrate that the technology could be used to conduct a visit with patients in their homes, while connected to a remote provider, and that this visit would approximate the quality of an in-person encounter.

With some technical limitations, we felt this was achieved. We also noted an extremely high level of satisfaction from patients and family members or caregivers.

Some patient stories: Some of the patients, and circumstances that we encountered, were quite upsetting, even for us as urban core primary-care providers. When we see patients in our office, we often do not get a full appreciation of the difficult social circumstances they face.

We get it intuitively, but often the reality is eye-opening. This project was eye-opening.

We provided care for one patient, Anne, who we met after she was diagnosed with stage 4 cervical cancer. Anne had severe agoraphobia, for which she was not medicated. She also had bony metastases as a result of her cancer. This is generally regarded as one of the most painful conditions treated in medicine. Anne was in significant pain, but she could not leave her house.

In her case, the fear of leaving her house was more significant than the pain that she experienced due to her cancer.

Anne was thrilled at the availability of a Virtual House Call. Over many weeks we saw her several times. We provided her with pain medication and we managed her anxiety, and she never left her home.

As things progressed, Anne worsened and she requested to be transferred to hospice care, which she noted was something she had wanted all along but was afraid to consider due to her anxiety.

With proper treatment she became a different person. A few weeks later she noted that her wish was to have a peaceful death in hospice, but her anxiety had precluded her from doing that. She no longer felt this way.
Two weeks later, she was transferred to hospice care at her request, where she died peacefully. There are many other anecdotal stories like this one, including one Virtual House Call that we performed to a patient who had neither heat nor electricity. We conducted this visit by flashlight!

I imagine as other front-line providers read this article, patients will come to mind who would clearly benefit from this technology and service.

In time, it is my hope that we can find more resources and opportunities for collaboration to make this service more widely available.

Limitations: When the first version of this service was offered, in 2017, the discussion around integrating digital health into the Canadian system was in its infancy.

There was limited ability to integrate this care with other services, and while we had good success with conducting encounters with patients, we struggled to integrate this service into their healthcare and often lost track of patients as they traversed the healthcare system.

Admission to hospital in some instances was unavoidable, and subsequent discharge did not return the patient to our care. Moving forward, and with greater awareness of the benefits of digital health, improved integration of these types of services should prove beneficial.

More resources will be required to demonstrate the magnitude of the benefit with respect to reduced hospital admissions and ER visits, among other things.

Technical limitations: Early technical limitations related primarily to the quality of objective information obtained in the course of conducting an assessment and making a diagnosis and treatment plan.

Videoconferencing capabilities have supported the collection of subjective information, i.e., history, for a long time.

Many software platforms provide the required security for this encounter. The challenge, however, lies in the physical exam. Early stethoscopes proved technically limited in several ways.

Higher level Bluetooth stethoscopes that are very similar to traditional stethoscopes promised connectivity, but in practice, they were not overly reliable, especially for remote use in real-time (asynchronous remote care is another topic entirely!)

The quality of the acoustic information was good, but unreliable.

Basic USB enabled stethoscopes, such as the one that we ultimately used, offered easy connectivity (to REACTS, not all platforms) but limited quality of information.

These stethoscopes do not offer the ability to adjust the frequency settings. This is critically important for digital auscultation as background noise is a much more significant factor than in person auscultation.
High-frequency sounds, such as lung sounds, require different settings in digital auscultation than low-frequency sounds such as heart sounds. The device that we used performed well at low-frequencies (heart sounds), but poorly for higher-frequency sounds (lung sounds).

Accordingly, auscultation of the lungs was of low-quality, and in some instances rendered the visit technically suboptimal. After each visit a telemedicine provider should assess whether or not the visit approximated an in-person encounter; if it did not, then the patient should be notified of this concern and the assessment and plan may be modified.

Summary: Virtual House Calls are technically feasible and result in high levels of patient and caregiver satisfaction. Technological advancements since the inception of this program have made this service even more beneficial, such that it is rare that a trained provider would be unable to approximate an in-person visit.
More study is required to produce information on the scalability of this service and the cost savings that will be realized. Consideration will have to be given to the fact that acquiring data requires an investment.

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